Provider Demographics
NPI:1497824106
Name:MADISON WOMEN'S CLINIC, PLLC
Entity Type:Organization
Organization Name:MADISON WOMEN'S CLINIC, PLLC
Other - Org Name:MADISON WOMEN'S CLINIC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:CLINTON
Authorized Official - Last Name:BARTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-356-6185
Mailing Address - Street 1:15 MADISON PROFESSIONAL PARK
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440
Mailing Address - Country:US
Mailing Address - Phone:208-356-6185
Mailing Address - Fax:208-356-0378
Practice Address - Street 1:15 MADISON PROFESSIONAL PARK
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440
Practice Address - Country:US
Practice Address - Phone:208-356-6185
Practice Address - Fax:208-356-0378
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2012-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002756800Medicaid
ID1377255Medicare ID - Type Unspecified
ID002756800Medicaid